Hymenal injury is considered to be nearly pathognomonic of child sexual abuse. Accidental injury of the hymen is felt to be a rare event. Child abuse experts often cite cases of picket-fence or bedpost impalements as the exception, and dismiss the likelihood of accidental injury to the hymen. Despite this sentiment, accidental injuries of the anogenital region, including the hymen, have been described in the literature. The following case documents such an accidental injury, and follows the injuries from the acute stage through initial healing.
A 7-year-old white girl presented to the emergency department with the chief complaint of vaginal bleeding after a fall in the bathtub. The physician who examined her noted vaginal blood with no clear source and consulted a staff pediatrician experienced in evaluating child abuse.
The patient was a comfortable, articulate child who readily agreed to being interviewed alone. She gave a history of “bowling” in the bathtub and hurting herself on the “horse's shoes.” On a request for elaboration, she recounted a connected narrative in which she had completed a shower and was setting her toy horses up at the drain end of the tub and sliding down the wet porcelain into them, knocking them down. On the final repetition of this game, she lost her balance, her legs went up in the air, and she hit the horses hard, causing pain in her genital area. She stood up and cried, touching her genital area with her hand, and then noted blood on her hands. Her father came in and blotted her with a towel. Shortly thereafter, her mother came home and used a spray bottle to clean her further. This was painful to her. Her parents then decided to bring her to the emergency department.
Besides the above narrative, the patient also provided a rich supply of extraneous detail, which wove these events into the fabric of everyday life. She stated that her mother prefers her to shower not bathe, because she runs the bath too full, and that her mom does not like her to play a long time in the tub, but she does because it is fun. She indicated that she had used Barbie's horse, which hurt her, and another, which did not because it is “smaller and soft.” Barbie's horse was described as “white.” A request for other notable features produced the remark that the horse's hooves are sharp. When asked how she knows this, she replied that she had felt them with her fingers. She reported that she had bathed herself with soap and a washcloth, and shampooed and conditioned her hair. When the examiner remarked that she should be clean then, she reported that her hair should smell good “like strawberries.” She referred to the spray bottle as the “cat bottle” because it is used to spray the cat when it gets up on the couch. The patient denied inflicted trauma to her genitals or being told what to say to the doctor.
The general physical examination was unremarkable. Colposcopic examination of the genitalia was conducted in frog-leg position with labial separation and traction and in knee chest position. The genitalia were soiled with bright red clotting blood. The labia majora, clitoris, and clitoral hood showed no evidence of trauma. The right labia minora demonstrated a shallow tear or abrasion at its inferiolateral base. The posterior forchette was intact, and the fossa navicularis demonstrated a small oval abrasion at 7 o'clock, halfway between the forchette and hymen (Fig 1). The hymen itself demonstrated a pinpoint petechia at 2 o'clock; a full transection at 6 o'clock surrounded by friable abraded tissue; a similar but partial-thickness laceration at 8 o'clock; and friable abraded mucosa covering the hymenal tissue between the two lacerations (Fig 2). The posterior wall of the vagina was well-visualized. Rugation and a posterior column were noted but no signs of trauma were seen.
The child was reexamined after 3 days and again after 2 weeks. At the 3-day examination the extrahymenal lesions were resolved, and granulation tissue was noted along both margins of a swollen and apposed transection at 6 o'clock and across the introital surface of the hymen to the laceration at 8 o'clock (Fig 3). At the 2-week examination all swelling and granulation tissue had resolved and all surfaces were reepithelized. The hymen demonstrated a full-thickness transection at 6 o'clock and an angular notch at 8 o'clock (Fig 4).
Photographic slides of the examination were presented to the Northern California Medical Examiners Group, a peer review group of sexual abuse examiners. The 2-week examination was presented first with minimal history. Group consensus, without dissent, was that the examination was consistent with penetrating trauma of the hymen suggestive of child sexual abuse. The full history and earlier photographs were then presented. The group found the history credible and consistent with findings. In light of their experience and the literature, they felt the relative lack of extrahymenal injury was remarkable.
As with many possible abuse situations, the history in this case is critical. This child presents a connected but idiosyncratic narrative of events from her own perspective. Her history is rich in associated and extraneous detail and embedded within the context of family life. She readily answers additional questions without signs of stress and specifically denies abuse or being coached in her history. She includes appropriate emotional and sensory content including smells. These factors have been associated with credible histories from children.1 Without this history it is likely that her injuries would have been attributed to sexual trauma.
Much accidental anogenital injury literature concentrates on its surgical consequences.2–6 A search of the literature yielded four case series, describing 161 incidents of accidental trauma to the genitalia of prepubertal girls. West et al7reported 13 girls with accidental injuries of the vulva. No hymenal injuries were noted. Bond et al8 reported 56 girls suffering “unintentional” injury to the perineum. One patient had a pinpoint abrasion of the hymen at 3 o'clock. This girl had fallen in a “splits-type mechanism” abducting her legs. No associated tear or other injury was noted. Pokorny et al9 described 32 girls with acute genital injury, 25 of whom were not suspicious for sexual trauma. Three of these girls had a hymenal injury, all described as a transection. One had jumped into a wading pool, landing on a toy. One slid down a tree trunk onto a protruding stump. The last was penetrated by a physician's finger during an examination. Notably, in the Pokorny series, while both sexual and accidental hymenal injuries were described as “symmetric” they were characterized as “distinctly different” attributable to enlarged introitus, major laceration, or hymenal attenuation in cases of sexual trauma. Dowd et al10 described 100 children with straddle injuries. Sixty-seven of the children were girls, 2 of whom had hymenal injuries. The hymenal injuries were described as a 5-mm tear from a “plunger injury” and a hematoma from a straddle injury on a bicycle crossbar. Additionally, the authors reported 5 abused children with falsified histories of accidental injury. These were felt to be easily distinguishable because of severe or extensive injury, other nongenital injury, or a large hymenal diameter.
These 161 cases of accidental trauma to the genital area resulted in 6 hymenal injuries for a rate of 3.7%. Follow-up in these cases was limited to complications and surgical consequences of the more serious injuries. Acute accidental injury of the hymen was felt to be easily distinguishable from sexually derived injuries. No description of the appearance of the healed hymen was included.
Most sexual abuse examination literature concerns the findings of old, healed, or chronic abuse injuries to the hymen. Serial photographs detailing the healing process of acute sexual trauma have been published.11 In many respects, this case is similar to case number 3 of that series. Differentiating factors, in this case, are the extensive abrasion of the introital surface of the hymen from 6 to 8 o'clock. It would be tempting to attribute this and the oval abrasion in the fossa navicularis to the sharp edges of the horse's foot. Healing of this child's injuries proceeded similar to the published cases and resulted in a persistent posterior cleft usually considered evidence of previous sexual assault.12
Two elements of this case are particularly notable. First, the history is not of a dramatic, horrific impalement. This child slid into her toy along the wet porcelain. Had reporting been delayed or the child unable to give such an excellent history, it may have been tempting to dismiss the given history in favor of suspected sexual abuse. Second, possibly in the acute phase and certainly at the 2-week follow-up, these injuries, taken alone, are consistent with and suggestive of sexual trauma. Unlike the authors of previous case reports, the peer review group did not find these injuries clearly distinguishable from sexual abuse.
Accidental trauma is an unusual cause of hymenal trauma. It can, however, produce findings suggestive of sexual abuse. Such cases are only distinguished by a clear and detailed explanatory history. The history of the accidental event should be painful, bloody, and memorable, not occult or speculative. The injury must account for penetration of the genitalia. The presented case illustrates the significant hymenal damage that can result from penetrating trauma, the similarity between healed accidental and sexual penetrating trauma, and the sort of history that would be necessary to distinguish rare, accidental hymenal injury from more common sexual trauma.
- Received September 14, 1998.
- Accepted December 22, 1998.
- Address correspondence and reprint requests to Stephen C. Boos, MD, University of California, Davis, Medical Center, Center for Child Protection, 2516 Stockton Blvd, Sacramento, CA 95817.
- Jona JZ
- McAleer IM,
- Kaplan GW,
- Scherz HC,
- Packer MG,
- Lynch FP
- West R,
- Davies A,
- Fenton T
- Bond GR,
- Dowd MD,
- Landsman I,
- Rimsza M
- McCann J,
- Voris J,
- Simon M
- Copyright © 1999 American Academy of Pediatrics